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Cycle 8 (2019 Deadline)

Promoting hand hygiene through production and use of locally produced alcohol hand-rub in health facilities in Uganda

PI: Esther Buregyeya (, Makerere University School of Public Health
U.S. Partner: Christine Moe, Emory University
Project Dates: April 2020 - December 2022

Project Overview:
Water, sanitation, and hygiene in healthcare facilities (HCFs) are critical for the provision of quality health care and prevention of hospital-acquired infections (HAIs). The healthcare-associated pathogens that can lead to HAIs are mainly transmitted through contact with contaminated hands of healthcare workers. HAIs represent the most frequent adverse event affecting hospitalized patients, resulting in increased morbidity and mortality. These infections are even more dangerous in this era of increasing anti-microbial resistance (AMR). Effective infection prevention and control measures prevent HAIs and help contain AMR. In particular, hand hygiene is recognized as the single most important practice to reduce HAIs and has been associated with sustained decrease in the incidence of AMR infections in healthcare settings. Though the importance of hand hygiene is well documented and recognized, evidence shows healthcare workers’ compliance is suboptimal in many settings, including Uganda. Factors found to affect hand hygiene compliance include poor access to sinks and hygiene supplies. Availability of an alcohol-based hand-rub at the point of care has been shown to increase hand hygiene. Alcohol-based hand-rub is currently recommended as the primary tool for hand hygiene action and promotion because it reduces bacterial counts on hands more effectively and can be more accessible than sinks. In addition, it can be locally produced at the HCF, making it even more accessible. However, locally made alcohol hand-rub intervention and research is limited in Ugandan UCFs.

To address this problem, the PI Dr. Esther Buregyeya and her team will develop a behavioral intervention to foster hand hygiene compliance using locally-produced alcohol- based hand-rub and assess the acceptability, feasibility, effect, and cost of using such hand-rub on compliance among health care workers in primary HCFs in Uganda. Expected outcomes of the study include improved hand hygiene and newly acquired skills in alcohol hand-rub production. U.S. partner Dr. Christine Moe is an experienced WASH expert in Uganda and other sub-Saharan countries who will contribute her knowledge and experience to facilitate the implementation of the study. The project fits well with the goals of Uganda and USAID in addressing the challenges of communicable diseases, with a focus on AMR and other emerging infectious diseases. Uganda is facing a mounting challenge of antibiotic resistance and recently launched its AMR National Action Plan (NAP). It also has a One Health Strategic Action Plan that includes work to address AMR. Hand hygiene is one of the most effective interventions to prevent HAI and reduce the transmission of resistant organisms. Therefore, this research will be timely in providing much-needed evidence about effective interventions that can inform implementation of the NAP and help ensure the future safety of patients, health workers, and communities in Uganda. In addition, recent global public health emergencies, such as Ebola disease outbreaks, have highlighted gaps in infection prevention and control (IPC) measures. Uganda lies in the Ebola “hot zone” and has experienced repeated outbreaks, including in 2019 in the neighboring Democratic Republic of Congo. In this situation, alcohol-based hand-rub is a very essential component of IPC. Therefore, developing interventions to foster hand hygiene compliance, such as promoting locally-produced alcohol-based hand rub, is critical for general health system resilience in Uganda and sub-Saharan Africa.

Summary of Recent Activities:

In the third quarter of 2021, Dr. Buregyeya and her team continued analyzing the formative phase data from their study and worked on drafting manuscripts. They received news that the abstracts they submitted to the International Meeting on Emerging Diseases and Surveillance (IMED) 2021 conference of the International Society for Infectious Diseases were accepted for e-poster presentation. The conference was held virtually November 4-6, and team members presented the following:
  • “Assessment of the Implementation of the Multimodal Strategy and Barriers for Hand Hygiene Improvement during COVID-19 Pandemic in Wakiso District, Uganda,“ abstract ID# 905.
  • “Perceptions and Attitudes towards Patients’ Role in Promoting Hand Hygiene among Health Care Workers in Wakiso District, Uganda,“ abstract ID# 911.
A second wave of COVID-19 that hit Uganda from June to August 2021 caused some delays for the team because of lockdowns that were instituted, but that situation had eased by the end of the third quarter. Meanwhile, another challenge arose when the proposed alcohol hand-rub production site for the project (Entebbe Hospital) was designated as a COVID-19 treatment site. This meant that other non-COVID patient services were suspended and as a result, the facility’s health workers were unable to participate in the intervention component of the study. Dr. Buregyeya and her colleagues are negotiating with the hospital to determine if they can still be a production site but not participate in the study.

The project team has applied for and received an extension to their Institutional Review Board approval and a no-cost extension from the PEER program so they can continue their work through June 2022. Plans for the remainder of 2021 and early in the next year include conducting stakeholder meetings to refine the intervention, training health workers on hand hygiene promotion, and resolving the uncertainty regarding the ability of Entebbe Hospital to serve as a hand-rub production facility.

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